Healthcare Provider Details

I. General information

NPI: 1295016780
Provider Name (Legal Business Name): JESSICA MARIE WILDER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2011
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 EISENHOWER DR
SAVANNAH GA
31406-2668
US

IV. Provider business mailing address

318 MALL BLVD #300B
SAVANNAH GA
31406-4797
US

V. Phone/Fax

Practice location:
  • Phone: 123-556-2559
  • Fax:
Mailing address:
  • Phone: 912-358-1515
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number75407
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number75407
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: